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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOA 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health S�'4eervices. Job Address 1 (, 3 :13 :1 3 1 —S+.I I/� � J City14 Lot Size/Acreage Owner's Name4.J Address Phone Contractor r Address 661e, License No. Phone tmmkav TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ C] Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'I Public (:1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth ( I Eastern Surface Seal Installed by W Repair Work Done O Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth 41- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic systest permitted if public sewer is to j/ available within`200 feet.) Installation will serve: Residence v Commercial_ Other Number of living units: Number of bedrooms Ci Character of soil to a depth of 3 feet: - if"d Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines �� Tgtal length/size FILTER BED ❑ Distance to nearest: Well..... f Foundation- J / Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requ.ed ipspections. Complete drawing on reverse side. r Signed X Title: 'j >1 Date: 7 ��OR DEP TMENT USE ONLY ZAA0 Application Accepted bye �,t•� Dateea -45�161K Pit or Grout Inspection by Date Final Inspection by Date?�" Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK V CASH RECEIVED BY DATE PERMIT'NO. EH 13.21 IREV.I/x 51 (� r 0(0 G `, 9a -- l•32y . EN SI•Te